자렐토(rivaroxaban) 복용 중인 74세 남자 환자에서 용종 절제술 시 혈전과 출혈 위험

CHA2DS2-VASc : 고혈압(1점), 74세(1점)

- 심부전 아님, 75세 이상 아님, 당뇨병 없음, 뇌혈관 질환 과거력 없음, 말초혈관 질환 없음, 성별은 남성

- 2점이므로 moderate thrombic risk에 해당

​

Perioperative thrombotic risk

Risk stratum	Indication for anticoagulant therapy
	Mechanical heart valve	Atrial fibrillation	VTE
Very high thrombotic risk*	Any mitral valve prosthesis Any caged-ball or tilting disc aortic valve prosthesis Recent (within six months) stroke or transient ischemic attack	CHA2DS2-VASc score of ≥6 (or CHADS2 score of 5-6) Recent (within three months) stroke or transient ischemic attack Rheumatic valvular heart disease	Recent (within three months) VTE Severe thrombophilia (eg, deficiency of protein C, protein S, or antithrombin; antiphospholipid antibodies; multiple abnormalities)
High thrombotic risk	Bileaflet aortic valve prosthesis and one or more of the of following risk factors: atrial fibrillation, prior stroke or transient ischemic attack, hypertension, diabetes, congestive heart failure, age >75 years	CHA2DS2-VASc score of 4-5 or CHADS2 score of 3-4	VTE within the past 3 to 12 months Nonsevere thrombophilia (eg, heterozygous factor V Leiden or prothrombin gene mutation) Recurrent VTE Active cancer (treated within six months or palliative)
Moderate thrombotic risk	Bileaflet aortic valve prosthesis without atrial fibrillation and no other risk factors for stroke	CHA2DS2-VASc score of 2-3 or CHADS2 score of 0-2 (assuming no prior stroke or transient ischemic attack)	VTE >12 months previous and no other risk factors

Refer to UpToDate topics on perioperative anticoagulation management for details.

VTE: venous thromboembolism; CHADS2: congestive heart failure, hypertension, age ≥75 years, diabetes mellitus, and stroke or transient ischemic attack; CHA2DS2-VASc: congestive heart failure, hypertension, age ≥75 years (2 points), diabetes mellitus, prior stroke or transient ischemic attack or thromboembolism (2 points), vascular disease (peripheral artery disease, myocardial infarction, or aortic plaque), age 65-74 years, sex category female.

* Very high-risk patients may also include those with a prior stroke or transient ischemic attack occurring >3 months before the planned surgery and a CHA2DS2-VASc score <6 (or CHADS2 score <5), those with prior thromboembolism during temporary interruption of anticoagulation, or those undergoing certain types of surgery associated with an increased risk for stroke or other thromboembolism (eg, cardiac valve replacement, carotid endarterectomy, major vascular surgery).

Modified from Douketis JD, Spyropoulos AC, Spencer FA, et al. Perioperative management of antithrombotic therapy: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 2012; 141(2 Suppl):e326S. Copyright © 2012. Reproduced with permission from the American College of Chest Physicians.

​

​

조직검사를 포함하여 진단적 내시경을 하는 것이라면 low-risk procedures.

용종절제술을 시행하는 것이라면 high-risk procedures.

Screening colonoscopy는 uncertain bleeding risk인데 그 이유는 1 cm 이상의 큰 용종에 대해 용종절제술이 필요한지 불확실하기 때문입니다. 하지 않은 상태에서 용종을 예측할 수는 없으니깐요.

​

Procedure-related bleeding risk from gastrointestinal procedures

Higher-risk procedures

Polypectomy*

Biliary or pancreatic sphincterotomy

Treatment of varices

PEG placement¶

Therapeutic balloon-assisted enteroscopy

EUS with FNAΔ

Endoscopic hemostasis

Tumor ablation

Cystgastrostomy

Ampullary resection

EMR

Endoscopic submucosal dissection

Pneumatic or bougie dilation

PEJ

Low-risk procedures

Diagnostic (EGD, colonoscopy, flexible sigmoidoscopy) including mucosal biopsy

ERCP with stent (biliary or pancreatic) placement or papillary balloon dilation without sphincterotomy

Push enteroscopy and diagnostic balloon-assisted enteroscopy

Capsule endoscopy

Enteral stent deployment (controversial)

EUS without FNA

Argon plasma coagulation

Barrett's ablation

EGD: esophagogastroduodenoscopy; ERCP: endoscopic retrograde cholangiopancreatography; PEG: percutaneous endoscopic gastrostomy; EUS: endoscopic ultrasound; FNA: fine-needle aspiration; EMR: endoscopic mucosal resection; PEJ: percutaneous endoscopic jejunostomy.

* Among patients undergoing colonic polypectomy, the size of the polyp influences the risk of bleeding, and it may be more appropriate to categorize polyps less than 1 cm in size as low-risk for bleeding.

¶ PEG on aspirin or clopidogrel therapy is low risk. Does not apply to dual antiplatelet therapy.

Δ EUS-FNA of solid masses on aspirin/nonsteroidal anti-inflammatory drugs is low risk.

Reproduced from: ASGE Standards of Practice Committee, Acosta RD, Abraham NS, et al. The management of antithrombotic agents for patients undergoing GI endoscopy. Gastrointest Endosc 2016; 83:3. Table used with the permission of Elsevier Inc. All rights reserved.

​

리바록사반(자렐토)을 복용 중인 low to moderate risk 환자에서는 시술 전 48시간 동안 약을 중단합니다. 시술 후에 지혈이 되었다면 약을 재투약 하기 전에 48시간을 기다립니다.

​

DOAC은 작용 시간이 빠르고(1-3시간), 반감기가 짧으며(5-17시간) 약물 투약 후 완전한 항응고효과는 투약 몇 시간 이내에 발생합니다. 이와 같은 이유 때문에(시술 직후 출혈 위험이 높아질 가능성) DOAC을 재투약하기 이전에 48시간을 기다립니다.

​

정리 ) 자렐토(rivaroxaban) 복용 중인 74세 남자 환자에서 용종 절제술 시 혈전과 출혈 위험

혈전 위험은 moderate(thorombic risk), 시술 출혈 위험은 진단적 대장내시경은 low, 용종절제술은 high

자렐토 중단은 시술 전 48시간 동안, 시술 후 48시간 후에 재투약 여부 결정

​

REF. UpToDate 2019.08.29

​